ERYTHEMA HYPERAEMICUM

Synonyms.—Erythema simplex; Erythema congestivum.

Definition.—Erythema hyperæmicum may be defined as a hy-
peremic disorder, appearing in the form of variously sized and shaped,
circumscribed or diffused, limited or more or less general, pinkish or red,
non-elevated patches.

The erythemata are usually divided into two general classes—
idiopathic and symptomatic. In the former are included all those
erythemata due to external agencies. In the latter, all those cases in
which the erythema precedes or accompanies systemic febrile disease;
and those due to disorders of the digestive tract, to the development
of intestinal toxins, and to the ingestion of certain drugs.

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HYPEREMIAS

Symptoms.—Of the Idiopathic Class.—The essential symptom is
redness, which may vary as to degree, but is without perceptible eleva­
tion or infiltration. It disappears under pressure, to reappear as soon
as pressure is withdrawn. It varies in extent in different instances,
dependent upon the amount of surface exposed to the etiologic factor,
most of the cases naturally being of a limited area.

If the cause continue, the condition may progress from an erythema
to a dermatitis; such cases will be considered under the latter head.
If the erythema occurs repeatedly in the same location, there may be,
in consequence, more or less pigmentation, but this is usually slight in
character.

In this class are to be found the erythemata due to heat and cold
—erythema caloricum. That due to artificial heat is sometimes desig­
nated erythema ab igne, and that occurring from the effects of the
sun‘s rays, erythema solare. The former is seen on the lower parts of
the legs of those who may be in the habit of sitting close to the fire,
such as cooks, stokers, and engineers. It appears as ill-defined red spots,
sometimes reticulated, and sometimes with a tendency to be gyrate and
annular; after cessation of the cause it may give place to moderate pig­
mentation.¹ The erythema due to the sun's rays is well known, being,
according to the duration of exposure and season, and in a measure to
the sensitiveness of the individual skin, from a light to a brilliant red
in appearance. Although heat doubtless has an influence in its produc­
tion, it is now known that the chemical or actinic rays of light play the
important part. Prolonged exposure, in those with sensitive skin, may
result in a dermatitis, usually of a vesicular character. Repeated ex­
posures result in gradual pigmentation which, owing doubtless to the pig­
ment protecting the parts from the actinic rays, leads to more or less
invulnerability.

Under erythema caloricum belongs also the erythema due to expo­
sure to cold,—erythema pernio, chilblains,—more frequently met with
in children and old people with feeble circulation. The common sites
are the heel, toes, ears, nose, and fingers. The affected part is dark
red, especially when it is brought in proximity to heat of any kind. It is
more or less in abeyance in mild weather, and is especially troublesome in
winter, particularly after being out in the cold. There is often consider­
able burning and sometimes, also, itching. The condition is frequently
persistent, and often rebellious to treatment.

The term erythema perstans, while usually applied to rare cases
having some of the features of erythema multiforme (q. v.), might also
be conveniently used to designate those cases of persistent stasic, more
or less livid, hyperemia or erythema involving, usually symmetrically,
the fingers, often extending upward to hands and lower part of fore­
arms; and sometimes involving also the feet and lower part of the legs.
The surface is usually cold, occasionally with an associated mild hyperi-

¹ Hartzell (“Erythema ab Igne,” Jour. Cutan. Dis., 1912, p. 462; with good illus­
tration) reports 4 cases, in one of which it was on the lower part of the back and the
result of the continued application of a hot­ water bag; histologic examination of one
case showed the affection to be clearly inflammatory, the name erythema ab igne being
preferable, therefore, to “ephelis ab igne?’’

ERYTHEMA HYPERÆMICUM                           145

drosis. There are, as a rule, no subjective symptoms. The causes are
obscure, doubtless varied; among which are probably cardiac weakness,
chilblains, and coal­ tar drug habits; and it may possibly be in some
instances a benign, persistent, stationary, early stage (with no disposi­
tion to progress) of Raynaud‘s disease.

Another source of the erythemata of the idiopathic class is trauma-
tism of mild degree—erythema traumaticum. This is due to pressure or
friction—as, for example, from tightly fitting garments, a truss, garters,
tight bandages, etc. It is localized, and disappears rapidly upon removal
of the cause.

Erythema paratrimma is a term, now almost obsolete, sometimes
applied to erythemata due to pressure, more particularly to the ery­
thema preceding the formation of a bed-sore. Probably of pressure
origin is that erythema seen not infrequently at the back of the neck
in infants, sometimes extending up into the hair—erythema nuchæ,
which is usually transitory.

Erythema venenatum is a name given to those simple erythemata
produced by the irritation of various mineral and vegetable substances,
such as mustard, arnica, strong soap, dye-stuffs, certain plants, and
the like.

Symptoms.—Of the Symptomatic Class.—Redness, disappearing
upon pressure, is likewise the essential symptom characteristic of this
class. The erythema varies in extent in different cases, and may consist
of but one or two insignificant patches, or the general surface may be
more or less covered. The emotional flushings, for instance, of which
repeated blushing is the mildest example, can doubtless be included under
this class. The color of the symptomatic erythemata varies usually from
a bright pink to red, but it may be of a darker hue, and may even be
somewhat livid. As a rule, there are no subjective symptoms, although
in some cases slight burning and a feeling of warmth may be experienced.
Itching is rarely present to any degree, and is usually entirely absent.
Several varieties may be referred to.

Erythema læve may properly belong in this class, although there
is a local element in its production, and it is usually persistent. This
refers to the shiny and glistening redness of the skin sometimes ob­
served in connection with edema of the legs.

Erythema fugax, as the term signifies, applies to those erythemata,
of obscure origin, which appear in one or more areas, and which are
capricious in their appearance and disappearance. Such an erythema
may appear suddenly, most commonly on some part of the face, and disap­
pear again in the course of a few minutes or several hours, to remain away
or to reappear. It is possibly allied to urticaria, although itching is
rarely present to any degree.

Erythema urticans is somewhat similar, but usually evanescent in
character and quite itchy. It is, as in almost all the cases of this class,
unattended by desquamation.

In other cases the erythema, or rash, is more or less general, pre­
senting either as areas or sheets of continuous redness or as closely
crowded or scattered red spots. Sometimes the redness is punctate,
10

i46                                         HYPEREMIAS

but as a rule it is uniform. Roseola is a term that has been applied
more or less indiscriminately to some of the symptomatic erythemata,
and may be regarded as a designation for the more or less general rashes
of this class; it is applied more particularly, however, to those erythemata
characterized by spots or patches, rather than by diffused rashes. The
symptomatic erythemata may be seen sometimes preceding or in the
course of some systemic diseases, such as vaccinia, diphtheria, variola,
etc, or they may arise from some stomachic and intestinal diseases and
from intestinal toxins. In the generalized rashes due to these latter
causes there may be some slight febrile action, which, however, soon
subsides. The erythema infectiosum of Escherich, Shaw,¹ and others
appearing in children in the spring and summer, and characterized by
somewhat generalized macular and patchy erythema, more especially
on the face, legs, and arms, with sometimes slight systemic disturbance,
is probably due to a mild toxemia of gastro­intestinal origin.

The rash of symptomatic erythemata may last from several hours
to several days, and exceptionally may show slight desquamation,
although this is never a striking feature except in the types more properly
coming under the head of erythema scarlatinoides, which will be de­
scribed separately. Drugs are also responsible for some of the erythe-
mata of this class, and these will be referred to again under dermatitis
medicamèntosa.

Diagnosis.—The diagnosis of most of the erythemata of the idio-
pathic class is usually readily made. The erythemata of the symptom­
atic group are occasionally somewhat obscure, especially in those in
which there may be some febrile action and constitutional disturbance.
The absence of the characteristic features of the rashes of measles,
scarlatina, and of the other symptoms of these diseases can be utilized
in questionable cases.²

Treatment.—The treatment of the various erythemata described
is purely of an expectant or symptomatic character. In the idiopathic
rashes a removal of the cause is, as a rule, all that is required. Dusting-
powders, mild lotions, such as are advised in erythema intertrigo, may be
prescribed, if necessary. The calamin-zinc-oxid lotion is admirably
suited for eczema solare, and may be used as a preventive measure.
For this last purpose pure calamin powder lightly dusted over the parts
will also have a preventive influence; this property is due to the pinkish
or reddish color of the calamin acting as an obstacle to the action of the
actinic rays.

In chilblain stimulating local remedies are, as a rule, required. An
occasional painting, every two or three days, with tincture of iodin,
pure or diluted with alcohol, at times acts well. Painting on several
coatings of collodion, at intervals of a few days, will, through the pressure
it exerts, also exercise a favorable effect. Applications of balsam of Peru
have gained a reputation in this affection, but like other drugs, it often
fails to exert an influence. Frictions with oil of turpentine, pure or

¹ Shaw, Amer. Jour. Med. Sci., Jan., 1905.

² Winfield, “Erythematous Rashes Simulating the Acute Exanthemata,” Brooklyn
Med. Jour., 1902, vol. xvi, p. 349.

ERYTHEMA 1NTERTRIGO

147

diluted with oil, have also cured some cases. The same may be said of
strong ointments—3 to 10 per cent, strength of carbolic acid and creasote.
Ichthyol is to be commended as a lotion, diluted with two or three parts
of water, or as an ointment of 25 per cent. strength. These various
applications should be made once or twice daily, according to circum­
stances.

In obstinate and troublesome cases the application of a mild gal­
vanic current—two or three milliampères, three or four times weekly
—will sometimes prove of value; the positive pole is to be applied to the
affected part, and the negative to a neighboring region, near the truncal
nerve, or it may be held in the hand.

If a case of chilblain comes under observation immediately after
its first appearance, mild applications, such as calamin-and-zinc-oxid
lotion; or a boric acid ointment, 10 per cent, strength, with one or two
grains of menthol to the ounce, may be prescribed.

In those susceptible to this condition warm clothing should be
worn, and, as a rule, warm water should be used in bathing the affected
part, which should then be well dried with a soft linen towel. As chil­
blains are most frequent in the weak and in those of debilitated con­
stitution and weakened circulation, tonics, such as strychnin, arsenic,
nitroglycerin, iron, and, in suitable cases, cod-liver oil, are often of im­
portance.

The symptomatic erythemata require but little treatment, but a
careful study of the individual case and the discovery of the cause will
indicate the appropriate remedies to be prescribed, and, what is more
important, will be of value in guarding against recurrences. In many of
these cases there is an absence of any recognizable factor, and in such a
good plan is to give a mild saline laxative, or, in children, as sufficient dose
of gray powder, to bring about free action of the bowels. Small doses of
intestinal antiseptics, such as are prescribed in erythema multiforme,
should also be prescribed. Cases of any severity should be kept indoors,
and if there is febrile action, the patient should remain in bed. Local
treatment is rarely required; if this is necessary, the simple dusting-
powders may be used, or, in exceptional instances in which there may
be burning and some itching, if the dusting-powder does not relieve, a
weak carbolic acid lotion, 0.5 to 1 per cent, strength, may be prescribed.

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